1. Principles of Patient Assessment in EMS By: Bob Elling, MPA, EMT-P & Kirsten Elling, BS, EMT-P

2. Chapter 11 – Detailed Physical Examination © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

3. Objectives Describe the patients on whom the EMS provider should perform a detailed physical examination (DPE). Describe the patients on whom the EMS provider should perform a detailed physical examination (DPE). Explain when the EMS provider would perform a DPE. Explain when the EMS provider would perform a DPE. Describe how and why the approach to the DPE is modified for children. Describe how and why the approach to the DPE is modified for children. List the three general types of closed soft tissue injuries that the EMS provider may discover during an examination. List the three general types of closed soft tissue injuries that the EMS provider may discover during an examination. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

4. Objectives (continued) Describe the various types of open soft tissue injuries that the EMS provider may discover during an examination. Describe the various types of open soft tissue injuries that the EMS provider may discover during an examination. List the body areas and specific assessment points for each. List the body areas and specific assessment points for each. Explain how the acronym DCAP-BTLS may be useful during the DPE. Explain how the acronym DCAP-BTLS may be useful during the DPE. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

5. Objectives (continued) Provide an example of when the DPE would not be performed by the EMS provider. Provide an example of when the DPE would not be performed by the EMS provider. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

6. Introduction The detailed physical exam (DPE) is a complete head-to-toe exam for the non- life or limb-threatening conditions. The detailed physical exam (DPE) is a complete head-to-toe exam for the non- life or limb-threatening conditions. The DPE is performed on trauma patients with a significant MOI. The DPE is performed on trauma patients with a significant MOI. The DPE is usually completed during transport unless there is a delay. The DPE is usually completed during transport unless there is a delay. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

7. Detailed Physical Exam For most patients assess in a head-to-toe direction. For most patients assess in a head-to-toe direction. For young children the toe-to-head approach is used to decrease fear and anxiety. For young children the toe-to-head approach is used to decrease fear and anxiety. Soft tissue injuries discovered are classified as “opened” or “closed.” Soft tissue injuries discovered are classified as “opened” or “closed.” © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

8. Closed Soft Tissue Injuries Contusion Contusion Hematoma Hematoma Crush injuries Crush injuries © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

9. Open Soft Tissue Injuries Abrasion Abrasion Avulsions Avulsions Incisions Incisions Lacerations Lacerations Punctures/penetrations Punctures/penetrations Amputations Amputations Impaled objects Impaled objects Major artery lacerations Major artery lacerations Crush injuries Crush injuries © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

10. Examine the Following Areas: Head Head Assess for DCAP-BTLS and crepitus Assess for DCAP-BTLS and crepitus Common injuries are contusions and lacerations, which bleed profusely Common injuries are contusions and lacerations, which bleed profusely Face Face Assess for DCAP-BTLS, crepitation and symmetry Assess for DCAP-BTLS, crepitation and symmetry Palpate facial bones for stability Palpate facial bones for stability Vision problems can result from instability Vision problems can result from instability © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

11. Examine the Following Areas: Eyes Eyes Assess for DCAP-BTLS, pupil response, and eye movement Assess for DCAP-BTLS, pupil response, and eye movement Note any discoloration in the anterior chamber and around the eye (Raccoon’s eye) Note any discoloration in the anterior chamber and around the eye (Raccoon’s eye) Nose Nose Assess for DCAP-BTLS, and fluid drainage Assess for DCAP-BTLS, and fluid drainage Drainage may include blood or CSF Drainage may include blood or CSF For patients that are immobilized, drainage may become an airway obstruction For patients that are immobilized, drainage may become an airway obstruction © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

12. Examine the Following Areas: Ears Ears Assess for DCAP-BTLS and fluid drainage Assess for DCAP-BTLS and fluid drainage Allow fluids to drain Allow fluids to drain Mouth Mouth Assess for DCAP-BTLS, crepitation, loose or broken teeth, swelling or laceration of the tongue or throat, unusual odors, discoloration, and drainage Assess for DCAP-BTLS, crepitation, loose or broken teeth, swelling or laceration of the tongue or throat, unusual odors, discoloration, and drainage Assess need for suction or airway adjuncts Assess need for suction or airway adjuncts © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

13. Examine the Following Areas: Neck Neck Assess for DCAP-BTLS, crepitation and JVD Assess for DCAP-BTLS, crepitation and JVD May be necessary to open c-collar to assess, maintain manual stabilization May be necessary to open c-collar to assess, maintain manual stabilization Chest Chest Assess for DCAP-BTLS, crepitation, symmetry and paradoxical motion Assess for DCAP-BTLS, crepitation, symmetry and paradoxical motion Listen to breath sounds Listen to breath sounds Note any scars Note any scars Apply chest compression to reveal rib fractures Apply chest compression to reveal rib fractures © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

14. Examine the Following Areas: Abdomen Abdomen Assess for DCAP-BTLS, guarding, rigidity, masses/bulging (pulsing or firm) or distension Assess for DCAP-BTLS, guarding, rigidity, masses/bulging (pulsing or firm) or distension Prior to palpation, listen for absence of bowel sounds (if feasible) Prior to palpation, listen for absence of bowel sounds (if feasible) Ask the patient about distension or bloating Ask the patient about distension or bloating Do not touch any masses Do not touch any masses Note any scars Note any scars Consider females of child bearing age to be pregnant Consider females of child bearing age to be pregnant © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

15. Examine the Following Areas: Pelvis Pelvis Assess for DCAP-BTLS, crepitus, and stability Assess for DCAP-BTLS, crepitus, and stability Apply pressure on pelvic ring and pubic synthesis Apply pressure on pelvic ring and pubic synthesis Reconsider the MOI for possible pelvic injury Reconsider the MOI for possible pelvic injury Posterior Posterior Assess back and buttocks for DCAP-BTLS and crepitation Assess back and buttocks for DCAP-BTLS and crepitation When patient is on a long board prior to the exam, use fingers to reach under When patient is on a long board prior to the exam, use fingers to reach under © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

16. Examine the Following Areas: Extremities Extremities Assess for DCAP-BTLS and distal PMS Assess for DCAP-BTLS and distal PMS Compare side to side and assess for strength and reflexes Compare side to side and assess for strength and reflexes Assess the range of motion (ROM) Assess the range of motion (ROM) With major degloving injury or amputation assess for bleeding With major degloving injury or amputation assess for bleeding Crush injuries have the potential for immediate complications when crush is a lengthy time Crush injuries have the potential for immediate complications when crush is a lengthy time © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

17. Priority Determines Care The DPE is conducted: The DPE is conducted: Only if time permits Only if time permits Usually enroute to the hospital Usually enroute to the hospital When the patient’s condition is critical the priority should be: When the patient’s condition is critical the priority should be: Necessary interventions Necessary interventions Serial initial assessments Serial initial assessments Transport Transport © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

18. Conclusion The DPE is a thorough head-to-toe exam of the trauma patient who has significant MOI. The DPE is a thorough head-to-toe exam of the trauma patient who has significant MOI. The approach differs for children (toe-to- head). The approach differs for children (toe-to- head). The DPE is completed enroute to the hospital if time and personnel permit. The DPE is completed enroute to the hospital if time and personnel permit. Report all findings to the next care giver and carefully document your findings. Report all findings to the next care giver and carefully document your findings. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.